In recent decades psychiatry has been medicalized. Researchers in epidemiology, genetics, pharmacology, and neuroimaging have found some causal links between body chemistry and personality disorders – and identified drugs that reduce or eliminate deviant or destructive behavior. Jonathan Glover, a professor of ethics at The School of Law, King’s College London “takes for granted the value of biological psychiatry.” He agrees as well scientific progress is reducing our ignorance about the relationship between deliberations, decisions, and behavior.

That said, Glover is deeply concerned about “the dark side” of current psychiatric practices. Mindful that homosexuality was once branded a personality disorder, Glover reminds us that “not everything a culture considers deviant should be medically treated.” Moreover, although they identify problems that are real, psychiatric categories are not nearly as obvious or as objectively determined as the elements on the periodic table. They can “seem like the colonial boundaries in Africa: lines drawn from outside, sometimes uniting very different tribes in one territory, sometimes dividing a single tribe between different territories.”

Therefore, Glover advocates a psycho-therapeutic approach to personality disorders that adopts a framework of thought at the intersection between “the mind-body problem and the problem of free will” that includes the subjective and unscientific categories” of autonomy, responsibility, identity and the values that constitute “a good life.”

In Alien Landscapes? Glover provides a wide-ranging examination of personality disorders (including psychopathology, borderline personality disorder, schizophrenia, autism, anorexia, and dementia) that is informed by interviews with patients at Broadmoor Hospital, evolutionary psychology, and philosophy. He makes a compelling case that context can – and should – complicate the unambiguous, all-or-none definitions of normality and pathology that continue to appear in “the cruder versions of psychiatry.”

Concerned above all with “free will,” Glover proposes that in treating all but the most extreme personality disorders, psychiatrists should, at one and the same time, recognize that the individual’s power to choose has been greatly impaired and that he or she must “accept agency rather than fatalism.” Pointing to admittedly preliminary findings that there is “no sharp boundary between drug addiction and other strong desires,” that “the key to addiction may not be pleasure itself but anticipated pleasure,” and that withdrawal symptoms are often not as horrific as their reputation, for example, Glover suggests that “the difficulty of escaping addiction is compounded by the self-fulfilling belief that it is too difficult.” Loving families, rewarding jobs, and participation in supportive therapeutic groups that examine the costs of choosing present benefits over future harms, assume that “willpower, like a muscle, can grow with exercise,” and that the “patient” is a rider as well as a horse, can help.

Glover also asks whether some “symptoms” should determine a diagnosis calling for psycho-pharmacological intervention. Some manifestations of grief, even those that are prolonged and accompanied by depression, he writes, may be normal. Indeed, bereaved spouses and Vietnam veterans suffering from combat trauma may even be “poorer” without grief: “Perhaps being fully alive means experiencing the deepest things, including painful ones.” Because harm is “a highly contested concept, charged with values,” and often viewed differently by the persons experiencing it and those around them, psychiatrists, Glover emphasizes, should listen before classifying or taking action, let alone medicating.

Glover understands that people with dementia, anorexia, and autism have lost a good deal of control over their own lives, “sometimes almost to a vanishing point,” and are often not the best arbiters of their own best interests. Because anorexics face an annual death rate of around 5.1 per 1,000 persons and the palpable evidence that the promise of control is an allusion, he notes, their claim that it is a lifestyle and not a disorder should be rejected. The core aim of psychiatry for people with these afflictions and others along the continuum of personality disorders, he insists, is to provide assistance in overcoming psychological conditions that impede “human flourishing”. This task, in turn, involves deciding “how far, when, and in what ways” individuals should be absolved of responsibility, in part or entirely, for their actions.

Along with loved ones, psychiatrists, according to Glover, should keep asking whether an action “is the expression of the illness or of the person.” They should recognize that disorders “can make people radically strange without obliterating all the human psychology they share with others.” And they should see things “from the apparently incompatible standpoints” of scientific empiricism and a subjective, humanistic perspective, deployed “with empathy but also with searching questions….which tells us so much that is not visible from the outside.”

Great to hear someone standing up for agency. Wish I heard more of it. Too much "help" is just providing people with reasons not to try. Agency declines from an already low level if there's not even the expectation of it.
As a writer on dopamine, I applaud this statement
“the key to addiction may not be pleasure itself but anticipated pleasure."
Thanks for telling us about this book.